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Articles by D. S. Berman
Total Records ( 4 ) for D. S. Berman
  R Hachamovitch , X Kang , A. M Amanullah , A Abidov , S. W Hayes , J. D Friedman , I Cohen , L. E.J Thomson , G Germano and D. S. Berman
 

Background— The goal of this study was to assess the clinical value of stress myocardial perfusion scintigraphy (MPS) in elderly patients (≥75 years of age).

Methods and Results— We followed up 5200 elderly patients (41% exercise) after dual-isotope MPS over 2.8±1.7 years (362 cardiac deaths [CDs], 7.0%, 2.6%/y) and a subset with extended follow-up (684 patients for 6.2±2.9 years; 320 all-cause deaths). Survival modeling of CD revealed that both MPS-measured ischemia and fixed defect added incrementally to pre-MPS data in both adenosine and exercise stress patients. Modeling a subset with gated MPS (n=2472) revealed that ejection fraction and perfusion data added incrementally to each other, further enhancing risk stratification. Unadjusted, annualized post–normal MPS CD rate was 1.3% but <1% in patients with normal rest ECG, exercise stress, or age of 75 to 84 years and was 2.3% to 3.7% in patients ≥85 years of age or undergoing pharmacological stress. However, compared with age-matched US population CD rates (75 to 84 years of age, 1.5%; ≥85 years, 4.8%), normal MPS CD rates were approximately one-third lower than the baseline risk of US individuals (both P<0.05). Modeling of all-cause death in 684 patients with extended follow-up revealed that after risk adjustment, an interaction between early treatment and ischemia was present; increasing ischemia was associated with increasing survival with early revascularization, whereas in the setting of little or no ischemia, medical therapy had improved outcomes.

Conclusions— Stress MPS effectively stratifies CD risk in elderly patients and may identify optimal post-MPS therapy. CD rates after normal MPS are low in all subsets in relative terms compared with the age-matched US population.

  A Abidov , R Hachamovitch , S. W Hayes , J. D Friedman , I Cohen , X Kang , L De Yang , L Thomson , G Germano , P Slomka and D. S. Berman
 

Background— We have advocated the use of a 5-category "normal," "probably normal," "equivocal," "probably abnormal," and "definitely abnormal" approach to final interpretation of myocardial perfusion single-photon emission computed tomography (SPECT). The prognostic value of expressing levels of certainty compared with a dichotomous normal/abnormal classification or categories for summed stress scores is unclear.

Methods and Results— Myocardial perfusion SPECT (MPS) was visually assessed using a standard semiquantitative approach, yielding summed scores that were used for preliminary interpretation using 5 levels of certainty. The interpreter was permitted to then shift the level of certainty in the final interpretation by 1 degree, based on nonperfusion MPS variables and available clinical information. To examine the prognostic value of expressing levels of clinical certainty, we evaluated 20 740 unique consecutive patients who underwent rest Tl-201/stress Tc-99m sestamibi MPS (34.3% vasodilator stress), of whom 845 (4.4%) were lost to follow-up and 1695 were excluded from prognostic analysis due to an early revascularization (<60 days after MPS). The remaining 18 200 patients (59.1% men; age, 65±13 years) were followed up for cardiac death for a mean of 2.7±1.7 years. During the follow-up, a total of 591 cardiac death events occurred. By univariable analysis, there were substantial differences in the distribution of follow-up cardiac death by the category of clinical MPS certainty. The clinical certainty was found to be an independent multivariable predictor of cardiac death in the study population and better identified patients at increased risk of cardiac death than the approaches based solely on the standard categories of summed perfusion scores or based solely on categories of segmental perfusion scores.

Conclusions— The use of multicategory reporting of MPS results incorporating nonperfusion MPS results and clinical information enhances risk stratification compared with both a dichotomous normal/abnormal approach or approaches based solely on segmental categories of perfusion scores. Whether this enhanced risk stratification based on the clinical certainty of the MPS interpretation leads to a more effective therapeutic regimen, tailored to the individual patient’s need, requires further prospective evaluation.

  L. J Shaw , J. K Min , J Narula , F Lin , C. N Bairey Merz , T. Q Callister and D. S. Berman
  Background—

Sex differences exist in the prevalence and severity of obstructive coronary artery disease (CAD). Limited data are available to explore sex differences in prognosis with coronary computed tomographic angiographic (CCTA) measurements of CAD including novel nonobstructive plaque extent.

Methods and Results—

A total of 1127 consecutive patients were clinically referred to 16-slice CCTA and followed for the occurrence of all-cause death. Time to death was calculated by univariable and multivariable Cox proportional hazard models. Four-year survival (92.1%) was similar by sex (P=0.52). Women more often had no coronary stenosis (54%) as compared with men (28%) (P<0.0001). Mortality worsened for both women (P<0.0001) and men (P=0.002) by the number of vessels with ≥50% stenosis. For women, overall mortality ranged from 3.5% for no CAD to 25.0% for women with 3-vessel plus left main obstructive CAD (P<0.0001). For men, overall mortality ranged from 2.7% for no CAD to 17.4% for males with 3-vessel plus left main obstructive CAD (P=0.002). Nonobstructive disease was prevalent in women (range, 24% to 66%) and men (range, 45% to 74%) ages 45 to ≥80 years. Nonobstructive CAD extent was a significant estimator of all-cause mortality when added to a model containing pretest CAD likelihood and obstructive CAD extent (P=0.039). For men, in a risk-adjusted model including pretest CAD likelihood and obstructive CAD, the number of nonobstructive lesions was not a significant estimator of mortality (P=0.9). For women, the relative hazard for mortality, in a multivariable model, was 1.3 per nonobstructive lesion (P=0.003), including pretest CAD likelihood and obstructive CAD as covariates. For women, risk-adjusted median mortality ranged from 2.9% to 10.9% for none to ≥4 nonobstructive lesions (P<0.0001).

Conclusions—

Based on our preliminary analyses, CCTA obstructive and nonobstructive CAD adds incremental value to clinical assessment for risk stratification. Moreover, the extent of nonobstructive CAD by CCTA predicts mortality in women but not in men and may be helpful to optimize therapeutic strategies for women.

 
 
 
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